Endovascular management of patients with critical limb ischemia

• Published in: Journal of vascular surgery 2011-04, Vol.53 (4), p.1020-1025
• Main Authors: Conrad, Mark F., MD, MMSc, Crawford, Robert S., MD, Hackney, Lauren A., BS, Paruchuri, Vikram, MD, Abularrage, Christopher J., MD, Patel, Virendra I., MD, Lamuraglia, Glenn M., MD, Cambria, Richard P., MD
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Amputation; Angioplasty, Balloon - adverse effects; Angioplasty, Balloon - instrumentation; Angioplasty, Balloon - mortality; Biological and medical sciences; Blood and lymphatic vessels; Boston; Cardiology. Vascular system; Critical Illness; Diseases of the aorta; Female; Humans; Ischemia - mortality; Ischemia - physiopathology; Ischemia - therapy; Kaplan-Meier Estimate; Limb Salvage; Lower Extremity - blood supply; Male; Medical sciences; Middle Aged; Patient Selection; Platelet Aggregation Inhibitors - therapeutic use; Proportional Hazards Models; Retrospective Studies; Risk Assessment; Risk Factors; Stents; Surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Ticlopidine - analogs & derivatives; Ticlopidine - therapeutic use; Time Factors; Treatment Outcome; Vascular Patency; Vascular surgery: aorta, extremities, vena cava. Surgery of the lymphatic vessels
• ISSN: 0741-5214; 1097-6809
• DOI: 10.1016/j.jvs.2010.10.088

Background Although percutaneous intervention (PTA) is considered first-line therapy for peripheral vascular disease in many scenarios, its role in critical limb ischemia (CLI), wherein anatomic disease is more extensive, remains unclear. In the present study, late (5-year) clinical and patency data for PTA in CLI are defined. Methods From January 2002 to December 2007, 409 patients underwent infrainguinal PTA ± stent for CLI (Rutherford IV-VI) of 447 limbs. Primary patency, assisted patency, limb salvage, and survival were assessed using Kaplan-Meier. Predictors of patency, limb salvage, and death were determined using multivariate models. Results Demographics included age (70 ± 12 years old), diabetes (65.8%), and dialysis dependence (13%). The superficial femoral artery was treated in 58% of the patients, 16% were limited to the crural vessels, 38% had multilevel treatment, and stents were placed in 26%. Eighty percent of patients received postprocedure clopidogrel. Mean follow-up was 28 months (0-83). Five-year primary and assisted patency were 31% ± 0.04 and 75% ± 0.04, respectively. Limb salvage at 5 years was 74% ± 0.038. Sixty-three patients had major amputations. Survival at 5 years was 39% ± 0.03. Multivariate analysis identified dialysis dependence ( P = .0005; 2.7 [1.6-4.8]), ≤1 vessel runoff ( P = .02; 1.5 [1.1-2.0]), and warfarin use ( P = .001; 1.7 [1.25-2.3]) as negative predictors of primary patency, but none of these were negative predictors of assisted patency. Dialysis dependence ( P = .006; 2.5 [1.3-4.8]), female gender ( P = .02; 2.0 [1.1-3.7]), and ≤1 vessel run-off ( P = .04; 1.8 [1.0-3.2]) predicted limb loss. Dialysis dependence ( P = .0003; 2.3 [1.5-3.5]), diabetes ( P = .04; 1.5 [0.5-2.1]), and poor run-off ( P = .04; 1.6 [1.2-2.1]) were predictors of mortality. Conclusion Although primary patency is low, excellent limb salvage rates can be achieved in patients with CLI through close follow-up and secondary interventions. These data, and the 12% annual death rate, validate PTA as first-line therapy in patients with CLI.